Is my dose too high?

Scott and Miko

Scott and Miko

Member
Miko has been on Elura for an appetite stimulant since September 30th, but it increases his glucose. The side effects of Mirataz transdermal made unusable. I’d rather have him eating with high levels than starving with lower levels.

We knew his glucose levels would rise and upped his insulin dose to compensate. We’re getting greens at nadir, but his preshot levels keep rising. Can someone look at my spreadsheet to see if I should lower his dose back to 1 or 0.75 units?
 
If the Elura is working to stimulate his appetite, I would continue with it as it’s very important that he eat and that you try to stave off weight loss. We can compensate with insulin if it raises BG. Now, I have also had side effects with Mirataz such as restlessness and even aggression toward other cats. It also can cause excessive vocalization. I usually use 1/2 or less of the strip length on the box (which is 1.5 inches) and often every other day instead of daily (depending upon the cat.). What was your experience?
 
I’m a little confused by the different doses recently. You have tried a few different doses but then there were no subsequent tests for is to see the nadir for those cycles.
How are you measuring those doses? Are you using U-100 syringes and the conversion chart?
 
I see that you are giving potassium pills. I have had very good results with the Vetoquinol Renal K+ powder mixed into wet food. All the cats I have used it with don’t seem to mind the chicken liver flavor and it helps raise potassium. Depending upon their levels, I give 1 scoop per day for borderline low potassium and 2 scoops per day for lower potassium. More can be given.
 
Suzanne & Darcy said:
If the Elura is working to stimulate his appetite, I would continue with it as it’s very important that he eat and that you try to stave off weight loss. We can compensate with insulin if it raises BG. Now, I have also had side effects with Mirataz such as restlessness and even aggression toward other cats. It also can cause excessive vocalization. I usually use 1/2 or less of the strip length on the box (which is 1.5 inches) and often every other day instead of daily (depending upon the cat.). What was your experience?
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We tried lower the dose to half the suggested length, but the side effects were not worth it. He lost coordination in his back legs, looked like he was drunk and would fall over in his litter box. It would take three days to clear his system and by that time it quit stimulating his appetite.
 
Suzanne & Darcy said:
What was the Prednisolone for? And the Zenequin?
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Miko was on long-term Pred for about 12 years to control his pancreatitis, bladder inflammation, and arthritis. The Pred worked well to ease those problems, but we had to slowly increase his dose from 2.5mg every other day to 5mg every day over that time period. Eventually the long-term steroid use is what made his diabetic. We wanted to try the Pred again to see if it would ease his arthritis and increase his appetite, but decided it wasn't worth it when his glucose started increasing and we didn't see improvements in his symptoms. We started Pred at the same time as the Elura. Maybe we didn't give it enough time, but usually we could see a difference in 24-48hrs.
 
Suzanne & Darcy said:
Do you give anything for pain with the IVDD? You certainly are dealing with a lot of health problems with Miko. It’s a lot to juggle.

With regard to the constipation, here’s a product I have not tried yet, but I wish I had known about for my boy. It’s made by the same people who make Visbiome Vet, which is a probiotic I have had great success with in my IBD cats.

https://visbiomevet.com/products/visbiome-vet-constipation-care-packets
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I currently mix 1/2 packet of Fortiflora Pro in with his wet food 2x a day. We had good luck with using regular Fortiflora as a food topper during the transition from wet to dry. I'm waiting on an order of Visbiome Vet. The only thing I'm worried about is he doesn't eat all of his wet food. I suppose I can either mix it with water and syringe it to him or mix it with a Churu to make sure he gets it all.
 
Suzanne & Darcy said:
I see that you are giving potassium pills. I have had very good results with the Vetoquinol Renal K+ powder mixed into wet food. All the cats I have used it with don’t seem to mind the chicken liver flavor and it helps raise potassium. Depending upon their levels, I give 1 scoop per day for borderline low potassium and 2 scoops per day for lower potassium. More can be given.
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His potassium level was 3.3 on September 26th. The pills are huge! I was splitting the pill into 10 pieces and wrapping it in a Lean Treat for dogs (which we used successfully for pilling him for years), but he now refusing those treats as well. I've recently been crushing the pills into powder and syringing it to him with Miralax. I'll have to look into the powder because it would be easier than crushing the monster pills.
 
Suzanne & Darcy said:
Do you give anything for pain with the IVDD? You certainly are dealing with a lot of health problems with Miko. It’s a lot to juggle.

With regard to the constipation, here’s a product I have not tried yet, but I wish I had known about for my boy. It’s made by the same people who make Visbiome Vet, which is a probiotic I have had great success with in my IBD cats.

https://visbiomevet.com/products/visbiome-vet-constipation-care-packets
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Miko gets weekly laser therapy, but we currently don't give him any meds for IVDD. Everything seems to have an unforseen side effect. The Pred raises his glucose. Opiates give him constipation and constipation. If there is something else to treat this I'm open to suggestions.
 
Scott and Miko said:
We tried lower the dose to half the suggested length, but the side effects were not worth it. He lost coordination in his back legs, looked like he was drunk and would fall over in his litter box. It would take three days to clear his system and by that time it quit stimulating his appetite.
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Oh that is really terrible! Some cats just can’t handle Mirataz. So sorry
 
Suzanne & Darcy said:
What is the dry food you are feeding? What is the wet food?
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I'm currently feeding Weruva Chicken Checkmate and Weruva Topsy Turvy for his regular wet food. When he won't eat that, then I'll give him Nulo Freestyle Silky Mousse Tuna & Shrimp. All of these are below 10% carbs. The Weruva is lower in phosphorus. The Nulo has a phosphorus content of 1.5, which is higher than I'd like for his CKD, but it could be worse and at least he is eating.

The dry food is Young Again Zero Mature. This food is low carb and low phosphorus for his diabetes and CKD. He seems to eat more dry than wet after the Elura.

A brief synopsis of his journey:
Miko had bladder inflammation and his urethra would block. We put him on Pred for that. That would happen once or twice a year. It started happening more so we started giving him pred every other day, then everyday to treat the bladder inflammation and his arthritis. This has been going on for over 10 years. He is fractious and his glucose is always elevated at the vets office. He started to have problems walking and not using stairs earlier this year. We dismissed the slightly elevated glucose as normal and the vet thought it was his kidneys causing problems. We continued the Pred and switched to high-carb kidney food. He continued to get worse. He wouldn't walk and I had to hold him up in the litter box. We stated him on laser therapy thinking it was the IVDD. I asked the mobile vet who does the laser therapy about diabetic neuropathy. They checked his glucose and it was 471 at our house. We switched food, started insulin, and weened off the Pred. Since then he has been diagnosed with megacolon.
 
So right now he’s not on Prednisolone but is still getting Elura? It may not be entirely the Elura to blame for the BG. He has some other inflammatory conditions that may be causing the rise in BG.
 
Have you ever given Glucosamine/Chondroiton to help with the FLUTD? I figure by this point you have tried everything because he’s had this condition for such a long time.
 
I feed my cats those Weruva foods also (to keep phosphorus low) and also Chicken Duck and Turkey Take a Chance as well as Chicken and Lamb Laugh Out Loud (don’t you love the quirky names!). I also have tried the ultra low phosphorus Wx foods by Weruva. So the foods you are feeding are good. Do you happen to know what his phosphorus level was at his last bloodwork? High phosphorous levels can also cause significant problems with hind leg weakness/inability to jump properly, etc. It’s good that you started the Zobaline as well. How long has he been on it?
 
Another thought…. I give one of my cats Adequan injections for arthritis. That can have benefits for the bladder. “Adequan, being composed of polysulfated glucosaminoglycans, provides the added potential benefit of supporting a healthy bladder by contributing the raw components used to construct and maintain its protective mucosal lining.”
 
Scott and Miko said:
Since then he has been diagnosed with megacolon.
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I know that a lot of the people in the FB Megacolon group swear by that Fiber Response food, although I am sure it’s high carb (and a dry food so also not optimal for a cat with CKD or FLUTD.) As you said, though, it’s paramount that he eat.
 
Suzanne & Darcy said:
So right now he’s not on Prednisolone but is still getting Elura? It may not be entirely the Elura to blame for the BG. He has some other inflammatory conditions that may be causing the rise in BG.
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He is not currently on Pred. I'm thinking the crazy glucose levels are from the Elura. I'm currently waiting on an order of Cyproheptadine to try as an alternative to Elura. The longer he is on the Elura the crazier his levels become. One of the vets wanted me to up his dose to 2 units twice a day. I had just given him 1.3 units and his nadir was 99. Upping him to 2 units would have sent him hypo. The Elura raises the glucose more after I give it in the PM than it does during the AM. If I up anything, then it would be more in the PM and less in the AM. Hopefully the new meds will be here tomorrow and will work so we can stop the Elura.

My original question about the dose being too high was because his preshot levels seem to be getting worse with higher doses. The nadirs are higher on smaller doses, but his preshot levels were lower too. So it seems like I can give him a smaller dose and have higher but stable levels, or I can give a higher dose and have good nadirs but high preshot levels.

We used to be on Dasaquin chewables for a long time. We stopped those earlier this year when everything went downhill.

Phosphorus level was 5.4 on September 26th.

You also asked about the Marboquin - that was for a recurrent UTI. The last two UAs were negative and he is no longer on antibiotics.

I've tried the WX line, but he doesn't seem interested. I've spent so much money on different types of food trying to find something that is good for him and he will eat. It's a struggle.
 
Okay. I looked at your labs from September. The phosphorus is above the more desirable range of 4-4.5, but not too bad. However, I have seen phosphorus levels rise very quickly in cats to extremely high levels. Have you thought about adding Aluminum Hydroxide powder to his food to help get that phosphorus down?

Also, his hematocrit is dropping. Are you giving B-Complex vitamins to help with that? The HCT isn’t low enough to warrant treatment with ESAs like Darbepoietin yet, but I have had good results in helping the hematocrit using Jarrow B-Right B-Complex divided into ten smaller (size 4) capsules.
 
Suzanne & Darcy said:
Another thought…. I give one of my cats Adequan injections for arthritis. That can have benefits for the bladder. “Adequan, being composed of polysulfated glucosaminoglycans, provides the added potential benefit of supporting a healthy bladder by contributing the raw components used to construct and maintain its protective mucosal lining.”
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We started Adequan (1 or two injections) and I still have it. We decided to stop because he wasn't eating. I'd be more than willing to restart Adequan after we get the eating figured out.
 
Scott and Miko said:
He is not currently on Pred. I'm thinking the crazy glucose levels are from the Elura. I'm currently waiting on an order of Cyproheptadine to try as an alternative to Elura. The longer he is on the Elura the crazier his levels become. One of the vets wanted me to up his dose to 2 units twice a day. I had just given him 1.3 units and his nadir was 99. Upping him to 2 units would have sent him hypo. The Elura raises the glucose more after I give it in the PM than it does during the AM. If I up anything, then it would be more in the PM and less in the AM. Hopefully the new meds will be here tomorrow and will work so we can stop the Elura.

My original question about the dose being too high was because his preshot levels seem to be getting worse with higher doses. The nadirs are higher on smaller doses, but his preshot levels were lower too. So it seems like I can give him a smaller dose and have higher but stable levels, or I can give a higher dose and have good nadirs but high preshot levels.

We used to be on Dasaquin chewables for a long time. We stopped those earlier this year when everything went downhill.

Phosphorus level was 5.4 on September 26th.

You also asked about the Marboquin - that was for a recurrent UTI. The last two UAs were negative and he is no longer on antibiotics.

I've tried the WX line, but he doesn't seem interested. I've spent so much money on different types of food trying to find something that is good for him and he will eat. It's a struggle.
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Here’s a good up to date list that I like for lower phosphorus low carb cat foods.
https://www.bizave.com/foodlists/CKD Diabetes Food List.pdf
 
Scott and Miko said:
We started Adequan (1 or two injections) and I still have it. We decided to stop because he wasn't eating. I'd be more than willing to restart Adequan after we get the eating figured out.
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The inappetance is probably the result of the high BUN making him feel lousy (nauseated). Have you talked to your vet about starting sub-q fluids at home? It can really make them feel a whole lot better. Perhaps his Creatinine isn’t really high enough yet to warrant fluid therapy though.
But as for Adequan, it’s usually prescribed like this:
Twice a week for four weeks. Once a week for 4 weeks. Then once a month (although it can be given more often depending upon the cat.)

Can you update your signature to indicate that he’s no longer on Mirataz or Zenequin.
 
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Suzanne & Darcy said:
The inappetance is probably the result of the high BUN making him feel lousy (nauseated). Have you talked to your vet about starting sub-q fluids at home? It can really make them feel a whole lot better.
But as for Adequan, it’s usually prescribed like this:
Twice a week for four weeks. Once a week for 4 weeks. Then once a month (although it can be given more often depending upon the cat.)

Can you update your signature to indicate that he’s no longer on Mirataz or Zenequin.
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I've updated my signature.

We just started fluids at home. We did 90ml twice the first week and he started to get congested. The vet said that it might be too much fluids for him. We've since done 50ml and 30ml, but I need to be more consistent with the amount and schedule.
 
Suzanne & Darcy said:
The inappetance is probably the result of the high BUN making him feel lousy (nauseated). Have you talked to your vet about starting sub-q fluids at home? It can really make them feel a whole lot better. Perhaps his Creatinine isn’t really high enough yet to warrant fluid therapy though.
But as for Adequan, it’s usually prescribed like this:
Twice a week for four weeks. Once a week for 4 weeks. Then once a month (although it can be given more often depending upon the cat.)

Can you update your signature to indicate that he’s no longer on Mirataz or Zenequin.
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And thank you so much for taking the time to help us!
 
I did find this about Elura:
Because Elura was found to increase blood sugar for several hours after administration in some cats, its use in diabetic or prediabetic kitties should be considered carefully and may not be appropriate.


I speculate that it cause insulin resistance due to causing the release of growth hormone. Excess growth hormone does cause insulin resistance. My cat had Acromegaly so I am unfortunately familiar with that.
 
Scott and Miko said:
I've updated my signature.

We just started fluids at home. We did 90ml twice the first week and he started to get congested. The vet said that it might be too much fluids for him. We've since done 50ml and 30ml, but I need to be more consistent with the amount and schedule.
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Do you mean he was congested in his head (like you could hear his breathing?) Do be careful with fluids. First you need to know that his heart is healthy. Over hydration is dangerous and can cause pleural effusion (happened to one of my cats.). So you are right to proceed with caution there. When first starting out it is best to start slowly with lower amounts given daily rather than more given less frequently— and to watch for signs of over hydration. Are you familiar with the site felinecrf.org? It is such a comprehensive website for CKD and more.
 
Now about what you really wanted to talk about… the dose…I would hold at 1.5 right now and not manipulate the dose. Let’s see how he stabilizes on 1.5. His nadirs are not bad. I am addicted to green numbers, but it’s not always possible or even the best in some complicated situations. With everything he has going on right now, blue nadirs are not bad. We want to keep him under the kidney threshold for as much time as possible though (so hopefully keep him out of yellow numbers as much as possible.)
 
Oh and one final thing about appetite and nausea. Ondansetron (Zofran) is a human med given to cats and is much more effective at treating nausea than Cerenia. Cerenia is effective in preventing vomiting. I would not necessarily stop the Cerenia though. It has anti inflammatory effects that are helpful in many cats. The two drugs work in different ways and can be used concurrently.
 
Suzanne & Darcy said:
Do you mean he was congested in his head (like you could hear his breathing?) Do be careful with fluids. First you need to know that his heart is healthy. Over hydration is dangerous and can cause pleural effusion (happened to one of my cats.). So you are right to proceed with caution there. When first starting out it is best to start slowly with lower amounts given daily rather than more given less frequently— and to watch for signs of over hydration. Are you familiar with the site felinecrf.org? It is such a comprehensive website for CKD and more.
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Yes, he started do get congested in his head. Sounded like he has a stuffy nose.
 
Suzanne & Darcy said:
Sorry to throw so much at you and to ask so many questions.
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No worries, I appreciate it! I just hope I'm answering everything.

I am familiar with Tanya's website. I've learned so much between here and there. Both sites have been a great resource (better than my vets). And my vets are much more comfortable with me doing things myself (like subq, adequan injections, etc.) myself at home because of everything I've learned through both sites. It's great to be educated, but it's an education I never wanted.

I'll ask about the Zofran today. Thanks again!
 
Scott and Miko said:
I currently mix 1/2 packet of Fortiflora Pro in with his wet food 2x a day. We had good luck with using regular Fortiflora as a food topper during the transition from wet to dry. I'm waiting on an order of Visbiome Vet. The only thing I'm worried about is he doesn't eat all of his wet food. I suppose I can either mix it with water and syringe it to him or mix it with a Churu to make sure he gets it all.
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I use Visbiome Vet too, the regular probiotic packets, but I haven’t tried the constipation care product. I’ve had a lot of improvement in my IBD cats with Visbiome. As for food toppers to stimulate appetite my cats also like Forti Flora. Another one they like is Pure Bites Freeze Dried chicken treats ground up in a blender. Sprinkle the chicken dust on the food.
 
Scott and Miko said:
His potassium level was 3.3 on September 26th. The pills are huge! I was splitting the pill into 10 pieces and wrapping it in a Lean Treat for dogs (which we used successfully for pilling him for years), but he now refusing those treats as well. I've recently been crushing the pills into powder and syringing it to him with Miralax. I'll have to look into the powder because it would be easier than crushing the monster pills.
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Exactly. I have always used the Renal-K powder because potassium pills are horse pills! It’s so much easier. I would do one scoop a.m. and 1 scoop p.m. with his most recent potassium level. He has plenty of room for the potassium to increase without worrying about it going too high.
 
Suzanne & Darcy said:
The only other question I have right now is how you were measuring the odd doses like 1.3 and 1.62? Calipers?
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U40 syringe with half unit markers. I'm eyeballing the weird measurements (for example, I would eyeball 1.75 units of insulin in the syringe. Then would eyeball half of the space between the stopper and the 1.5 marker to come up with 1.62). Not the most accurate way to do it, and consistency is going to be gone if anyone other than me gives the shot.

I was going to switch to U100 before the Elura, but I decided to stay with U40 because we giving doses that are easier to measure on the U40.
 
Suzanne & Darcy said:
I use Visbiome Vet too, the regular probiotic packets, but I haven’t tried the constipation care product. I’ve had a lot of improvement in my IBD cats with Visbiome. As for food toppers to stimulate appetite my cats also like Forti Flora. Another one they like is Pure Bites Freeze Dried chicken treats ground up in a blender. Sprinkle the chicken dust on the food.
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Yes! The Pure Bites chicken gets ground up and used as a topper on every bowl of wet food. Often I'll have to add more to the food a little later to have him keep eating.
 
Scott and Miko said:
U40 syringe with half unit markers. I'm eyeballing the weird measurements (for example, I would eyeball 1.75 units of insulin in the syringe. Then would eyeball half of the space between the stopper and the 1.5 marker to come up with 1.62). Not the most accurate way to do it, and consistency is going to be gone if anyone other than me gives the shot.

I was going to switch to U100 before the Elura, but I decided to stay with U40 because we giving doses that are easier to measure on the U40.
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Okay. Got it. If it gets to the point where he’s at a very small dose or if he seems to need fattened or skinnied doses, you can always use the U-100s (with half unit markings) and convert.
 
Suzanne & Darcy said:
How is everything going with Miko? He’s doing okay on this dose right now.
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Thanks for checking on us! Miko's numbers are slowly coming back down after stopping the Elura. The numbers are still elevated, but they are slowly decreasing. He seems to be feeling better with the lower numbers (eating, walking better, jumped on the couch this morning), and I'm definitely feeling better with his lower numbers (I thought I broke him after his numbers stayed elevated even after stopping the Elura). The 1 unit dose seems to be correct for right now. I got a little worried about a lower than expected PM preshot last night so I gave 0.75 units. I should have given the full dose based on his +4 reading of 147. I'll have to do some extra testing as his numbers drop to make sure he doesn't drop too much.

I also have Cyproheptadine and Zofran to try if needed in the future. Right now I'm seeing how he does without the added meds since we stopped the Elura. I currently crush everything and syringe his meds since he stopped willingly taking pills, and he has started to hide when he sees me coming with the syringe. I also ordered a potassium powder so I don't have to crush the huge pills. Hopefully this makes things easier and he continues to improve.

Thanks again for all your help!
 
Are you going back to the 1.5 dose?

I think the Kidney Support Gold is causing a jump in BG. It has vegetable glycerin which is a form of sugar and can raise BG. Maybe if you really want to give it to him you could do it in the morning with breakfast to (maybe?) minimize impact on BG.
 
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Suzanne & Darcy said:
Are you going back to the 1.5 dose?

I think the Kidney Support Gold is causing a jump in BG. It has vegetable glycerin which is a form of sugar and can raise BG. Maybe if you really want to give it to him you could do it in the morning with breakfast to (maybe?) minimize impact on BG.
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I was looking at my notes and noticed that sometimes his BG spikes around the time I give him Kidney Support Gold, too. It comes in a dropper and it seems like a trivial amount (5 drops), but I am stopping that to see if that is the cause. I also have a urine collection kit to check if he has another UTI. Also, he just started a new bag of Young Again Zero mature (maybe something wrong with the batch). I still have some left over Dr. Elsey's for dry food and switched him to that. I also just started Renal K+ potassium powder, but I don't think that would cause the spike. So many variables that my head is spinning.

I did give him 1.5 units this morning because his preshot reading was 344. His +4.5 hour reading was 123. His +7 reading at the vet was 128. The vet wants me to up his dose to 2 units twice per day. I think that's too much based on his numbers five days ago where 1 unit took him from 258 to 84, but I don't know. What do you think? I told the vet I would do 1.5 and monitor him over the weekend.
 
Scott and Miko said:
His +4.5 hour reading was 123. His +7 reading at the vet was 128.
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That’s not bad — in the lower blue (123) at +4.5 and 128 a few hours and a half later. Of course, I would have to account for meter differences. I don’t know if the vet uses a human or a pet meter. But the point is that he’s not doing bad at all and we just need to tweak the dose a bit.
 
Suzanne & Darcy said:
That’s not bad — in the lower blue (123) at +4.5 and 128 a few hours and a half later. Of course, I would have to account for meter differences. I don’t know if the vet uses a human or a pet meter. But the point is that he’s not doing bad at all and we just need to tweak the dose a bit.
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The reason I took Miko to the vet to get his potassium checked. They used that blood sample to check his glucose to verify that my meter is accurate. They aren't use to owners testing at home and actually told me not to do it. I'm a little mad because I asked for a full blood panel, but they only checked his potassium (it decreased slightly), sodium, chloride, and glucose.

I'll keep him on 1.5 units, limit his supplements to Miralax and Renal K powder, and try to get some extra tests in over the weekend. Thanks for all your help!
 
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